/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/,

/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96889-en.cckm

201611327

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Hem - Lymphoma

CSC HEM Romidepsin(28D:1,8,15) VER 10-3-16 (HL 4709)

CSC HEM Romidepsin(28D:1,8,15) VER 10-3-16 (HL 4709) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM ROMIDEPSIN(28D:1,8,15) VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B CORE AB, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AB
Expected-S Approximate, Expires-S+122, Routine
Pre-Labs (delete all that do not apply)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 1 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

HEPATITIS B DNA, ULTRA QUANT, PCR
Expected-S Approximate, Expires-S+122, Routine
Draw if Hepatitis B Core AB is positive.
Treatment Conditions
Treatment Condition A
Verify ECG obtained.
Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/22/2016 through 12/19/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
CUTANEOUS T-CELL LYMPHOMA: Piekarz RL, et al. J Clin Oncol 2009;27(32):5410-17.
Reference Information (2)
PERIPHERAL T-CELL LYMPHOMA: Pierkarz RL, et a. Blood 2011;117(22):5827-34.
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Treatment Condition A
Verify ECG obtained.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 2 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
DAY 8 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: romiDEPsin for
270 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: romiDEPsin for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: romiDEPsin for 270 minutes.
Day 8, Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 3 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Magnesium less than 1.7 mg/dL or Potassium less than 3.6 mmol/L or
Creatinine Clearance less than 30 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 4 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 5 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/20/2016 through 1/16/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 6 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
DAY 8 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: romiDEPsin for
270 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: romiDEPsin for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: romiDEPsin for 270 minutes.
Day 8, Cycle 2 – Planned for 12/27/2016
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 7 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Magnesium less than 1.7 mg/dL or Potassium less than 3.6 mmol/L or
Creatinine Clearance less than 30 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 8 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Magnesium, Potassium.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 9 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or
Magnesium less than 1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/17/2017 through 2/13/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 10 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 11 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
DAY 8 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: romiDEPsin for
270 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: romiDEPsin for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: romiDEPsin for 270 minutes.
Day 8, Cycle 3 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 12 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify pretreatment labs have been obtained: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Magnesium less than 1.7 mg/dL or Potassium less than 3.6 mmol/L or
Creatinine Clearance less than 30 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 13 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 14 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 4 – 2/14/2017 through 3/13/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Magnesium, Potassium.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 15 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
DAY 8 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: romiDEPsin for
270 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: romiDEPsin for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: romiDEPsin for 270 minutes.
Day 8, Cycle 4 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 16 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Magnesium less than 1.7 mg/dL or Potassium less than 3.6 mmol/L or
Creatinine Clearance less than 30 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 17 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 15, Cycle 4 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 18 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/14/2017 through 4/10/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 19 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
DAY 8 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: romiDEPsin for
270 minutes.
DAY 15 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 20 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: romiDEPsin for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: romiDEPsin for 270 minutes.
Day 8, Cycle 5 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Magnesium less than 1.7 mg/dL or Potassium less than 3.6 mmol/L or
Creatinine Clearance less than 30 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 21 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 22 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 4/11/2017 through 5/8/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 23 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 24 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
DAY 8 FOLLOW-UP
LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY ROOM APPOINTMENT: romiDEPsin for
270 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally), Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium; CHEMOTHERAPY
ROOM APPOINTMENT: romiDEPsin for 270 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: romiDEPsin for 270 minutes.
Day 8, Cycle 6 – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 25 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Magnesium, Potassium
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Magnesium less than 1.7 mg/dL or Potassium less than 3.6 mmol/L or
Creatinine Clearance less than 30 mL/min.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 4/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Cutaneous T-Cell Lymphoma (CTCL)/ Peripheral T-Cell Lymphoma (PTCL); THERAPY: romiDEPsin 14 mg/m2 IV on
Days 1, 8, and 15; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Prolongation of QTc has been observed with romidepsin. Use with caution in patients with baseline prolongation of QTc interval,
patients on anti-arrhythymic medications, or medications with associated QTc interval prolongation.
Note to All Staff (2)
Reactivation of Hepatitis B virus infection has occurred in patients with evidence of prior Hepatitis B infection. Consider monitoring
for reactivation and antiviral prophylaxis
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 26 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+7 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Magnesium, Potassium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Platelets less than 100K/µL or ANC less than 1000/µL or Magnesium less than
1.7 mg/dL or Potassium less than 3.6 mmol/ or Creatinine Clearance less than 30 mL/min
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 27 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

RomiDEPsin (ISTODAX) 25 mg in sodium chloride 0.9 % 500 mL bag
25 mg (rounded from 25.06 mg = 14 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Administer over 4 hours.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:39:41 PM Page 28 of 28
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org